Intravenous Immunoglobulins in Lupus Nephritis

Objective: The study is aimed at demonstrating the effectiveness of intravenous immunoglobulin (IVIg) in resistant lupus nephritis. Lupus nephritis was considered resistant when it failed to show adequate clinical and laboratory response to treatment with steroid, azathioprine and pulse cyclophosphamide in combination for a period not less than 1 year. Methods: During the past 7 years 4 subjects (M = 1, F = 3) with systemic lupus erythematosus (SLE) and lupus nephritis WHO IV were selected to receive IVIg. Their age ranged from 19 to 48 years. The 3 female patients had severe extrarenal manifestations including skin rash, photosensitivity, fever, headache and severe polyarthralgia requiring large doses of analgesics. The male patient had steroid-dependent, relapsing autoimmune hemolytic anemia (AIHA) in addition to extrarenal manifestations. All subjects had microscopic hematuria, proteinuria (2–6 g/24 h), hypoalbuminemia (24–33 g/l), mild renal impairment (serum creatinine 90–160 µmol/l) and active serology for SLE. These patients had not responded satisfactorily to several courses of steroids, azathioprine and pulses of intravenous cyclophosphamide in 23–180 months. All 4 patients were started and continued on IVIg as per our protocol. Results: During the 9 months to 7.5 years of follow-up, these patients showed excellent response to IVIg. Their extrarenal symptoms had totally disappeared, serological activity subsided, proteinuria decreased (0.5–2 g/24 h), serum albumin improved (30–42 g/l) and renal function remained stable. The subject with AIHA did not suffer any further relapses and his hemoglobin remained above 110 g/l with only 10 mg of prednisolone daily. Repeat renal biopsy done in 2 patients showed definite histological reversal of active lesions. Clinical and immunological improvements might be related to the modulation of macrophage T cell function and enhancement of suppressor T cell function. Conclusion: IVIg has shown excellent therapeutic effect as an alternative drug in treatment of renal and extrarenal manifestations of SLE, which are resistant to other modalities of treatment.